Brad Figler: I'm going to be talking about urethral reconstruction for urethral strictures as an outpatient and in an ASC. I have no disclosures.

This is anatomy that I'm sure is familiar to everyone here. The fossa navicularis is in the distal penis, just proximal to the meatus. Bulbar urethra is in the scrotum and perineum. And the membranous urethra is just distal to the prostate.

In terms of things that we can do for urethra reconstruction and ASC before surgery, I think patient selection is key. Comorbidities like coronary artery disease, obesity, and sleep apnea, make outpatient ASC surgery a little more difficult. Anticoagulants may increase the risk of inter-op or post-op bleeding, so these patients may benefit from closer monitoring post-operatively.

For patients on chronic opioids, it may be difficult to control pain post-operatively, and therefore, these patients may need longer period of observation.

In terms of procedure selection, you'll want to consider duration of surgery, blood loss, physiologic burden of surgery, as well as post-operative pain control, and any other specialized post-operative care that the patient may need.

Communication with the patient and caregiver is really important. So we have detailed handouts for each surgery that we give to patients at the clinic visit when they book the surgery, so they know what to expect after surgery and can plan around that.

Finally, a thorough diagnostic workup will allow you to predict what's going to happen in the OR, and avoid a situation where the patient has a more invasive or more painful surgery than you anticipated.

Things to do to optimize the surgery itself include local and regional blocks to minimize pain postoperatively. Good communication with nursing and anesthesia is essential, and can allow for a quicker and less painful recovery, better discharge planning, and shorter PACU stay. Longer surgeries require more recovery, so it's important to have a plan and to communicate with everyone in the OR ahead of time, so they can anticipate needs. And finally, small things like minimizing blood loss often result in a quicker and more predictable recovery.

After surgery, communication with PACU staff is helpful, as our comprehensive and accurate discharge instructions. These patients have a lot of questions after surgery, so you'll want to plan for an uptick in phone calls and EMR, and probably reserve some capacity in your clinic for seeing post-op patients with questions or concerns.

I'm going to move on now to surgical technique. I'll try to get through everything without going over. Penile urethral strictures are caused by lichen sclerosis, BPH surgery, and STDs. Workup includes retrograde voiding and/or pull back urethrograms. The penile urethra is fixed to the corpus cavernosum and not very robust, so excisional procedures are typically not used on the penis. Instead, we utilize a lot of tissue transfer with either a graft or a flap. The patient shown here had a long eight French stricture in his penile urethra. So we performed a ventral onlay with a fasciocutaneous flap.

This patient had a very narrow fossa navicularis stricture that was about a centimeter in length. We perform these urethroplasties through the meatus, so the scar's excised and a buccal mucosal graft is parachuted in through the meatus.

For patients with really severe penile urethral strictures, typically due to lichen sclerosis or failed hypospadias repair, we perform a staged urethroplasty. In the first stage, we apply buccal mucosal graft to the disease segment, and create a urethrostomy proximal to the repair. In the second stage, we tubularize the reconstructed urethra. In the two photos on the right, you can see how the graft and adjacent tissue soften up over time. This makes the second surgery a lot more reliable.

All of these penile reconstructions are amenable to an outpatient or an ASC setting. They can be somewhat technical, but pain is minimal with appropriate penile blocks. The surgeries are not physically demanding, and the postoperative course is predictable.

So moving on now to bulbar urethra strictures caused by trauma, instrumentation/surgery, radiation. Workup includes retrograde and sometimes avoiding urethrogram. The bulbar urethra is robust and redundant, so short strictures can be excised in the remaining urethral and sutured to each other.

When possible, we try to preserve blood supply to the corpus spongiosum. In the picture on the left, you can see that we preserve the bulbar artery. At the bottom right, there's enough mobility on the adjacent urethra to do an excision and primary anastomosis, without dividing this artery. For longer strictures, some form of tissue transfer is necessary. In the photo on the right, we're performing a dorsal onlay by suturing the buccal mucosal graft to the corpus cavernosum and then to the spatulated urethra. So bulbar urethra reconstruction's also very minimal to outpatient in a ASC setting. Pain is minimal with appropriate blocks, and post-operative course is also predictable.

Posterior urethral strictures caused by treatments for prostate cancer, or BPH, or trauma. Workup includes retrograde and voiding urethrograms. The status of the continence mechanism in the bladder neck and membranous urethra are really important parts of the treatment algorithm. So we often do cystograms to assess bladder neck function, and integrate urethroscopy to determine whether these structures are involved in the disease process. Reconstructive options depend, in large part, on etiology, status of the continence mechanisms in location. So I'll run through a few common types of posterior urethroplasties that we perform as an outpatient.

For patients with a focal membranous urethral stricture and an intact bladder neck, an excisional urethroplasty is a great option. For patients with a non-functional bladder neck, a sphincter-sparing approach is really useful.

This is a video of a sphincter-sparing membranous urethroplasty. The video is made by Reynaldo Gomez in Chile, a reconstructive urologist who allowed me to share it here. But you can see that he's dissecting the sphincter off of the membranous urethra. So for patients who don't have a good internal sphincter, and rely on the external sphincter for continence, this allows for excision of the diseased membranous urethra with maintenance of continence.

Brachytherapy strictures tend to be limited to the prostatic apex and membranous urethra, as you can see in the voiding urethrogram images at the bottom. In this case, it's pretty straightforward to perform an excision in primary anastomosis.

So recently, we've been able to offer more reconstructive options to patients with post-prostatectomy and anastomotic strictures. Jonathan Warner from Mayo Clinic developed a sheath that fits a five millimeter suturing device in a digital ureteroscope. So we can now offer these patients trans urethral incision and re-approximation, or what he calls TUIMR.

For patients who aren't candidates for, or who are failed TUIMR, we're also able to offer more formal reconstruction, either robotically, or via a perineal pre-rectal approach.

Like many of the surgeries that I discussed, these are technically involved, but not physiologically demanding or very painful, so amenable to outpatient or ASC surgery.

Thanks.